Sr. No 2A9UII040000105 FORM 4 MDBTL Version 1.

0/11-14
Mandate For Non-Aadhaar Based Subsidy Transfer
(To Be Submitted To LPG Distributor)

To,
Distributor (Name) SIDDH LAXMI HP GAS District GAUTAM BUDH NAGAR State Uttar Pradesh
Oil co. (HPCL)

Sub: Authorization to update my bank Account Details for receiving LPG Subsidy through NEFT
/NACH
I hereby affirm that I have only one subsidized LPG Connection. I also affirm that I do not possess an
aadhaar number and confirm my choice to opt for payment of amounts due to me towards LPG
permanent advance and refill subsidy through NEFT/NACH to my bank account. My LPG connection and
bank account details are as under:

PART A: LPG CONNECTION DETAILS (Attach copy of cash memo or blue book or certificate from
Distributor /OMC)
LPG Consumer No. 6 1 1 2 0 6
17 Digit LPG ID (Don’t
2 1 1 9 1 5 1 0 2 0 0 0 0 0 5 8 4
fill anything in X)
Name Exactly as it
appears in LPG
Mr. PRIYANKA SINGH
connection (In BLOCK
LETTERS)
Mobile Number + 9 1 7 5 0 3 3 4 2 8 1 0
*Please provide mobile no.in case you do not have mobile no you can give mobile no. of any of your
family member.
Please note that the mobile no. provided by you will be updated in the LPG database and will overwrite
the earlier mobile no. if any

PART B: PARTICULARS OF MY BANK ACCOUNT (attach copy of passbook or cancelled cheque)

Name exactly as it is in
the bank account(In PRIANKA SINGH
BLOCK Letters)
Bank Name FEDERAL BANK
Branch name HABIBPUR

IFSC Code F D R L 0 0 0 2 2 6 4

Bank Account Number 2 2 6 4 0 1 0 0 0 0 7 1 0 0

NOTE: All Fields in Part a & Part B above are mandatory
I hereby confirm that:
The facts stated above are true and correct to best of my knowledge and belief
I will advise any changes to the distributor /company
I shall not hold IOCL/HPCL/ BPCL/MoP&NG responsible for any delays/non receipt of subsidy in case of
change /closure /deactivation of my bank account or for any rejection by the bank or non- confidentiality
of the above information
I further confirm that I do not have aadhaar number as on date as soon as I receive the Aadhaar number
, I will link the same to my LPG consumer number by giving a copy of the same to my distributor and
also get it linked to my above bank account
I have attached a copy of passbook/ cancelled cheque with bank account details to this application
I also understand that any false declaration attracts punishment under India Penal Code

Place: ________________________ Date: 10/09/2019 Sign of Consumer ____________________________________

ACKNOWLEDGEMENT SLIP
Received Non Aadhaar cash Transfer mandate Form 4 from (name) Mr. PRIYANKA SINGH Con. No
611206 along with copy of passbook/cancelled cheque

Date____________________sign& stamp of LPG Distubutor